10/18/2012

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www.pspbc.ca

BC Practice Support Program: End of Life Care Module

Facilitating Practice Change

International Primary Palliative Care Research GroupOctober 2012

Dr. Cathy Clelland

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� Catherine A. Clelland, BMedSc, MD, CCFP, FCFP� Executive Director, Society of General Practitioners of BC

� Chair, EOL PSP Module Development Working Group� GP Services Committee Staff Support

� There is no corporate or other potential conflict of

interest in relation to this program/presentation

Conflict Disclosure Information

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� Background to the British Columbia (BC) provincial Practice Support module in End-of-Life (EOL) care.

� Clarify the components of a provincial model integrating home care, palliative care services with services being provided in General practitioners offices.

� Demonstrate the utility of the EOL algorithm

� Review the Early Evaluation findings

Objectives

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Practice Support Program:

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� Created to help family physicians in BC network with colleagues & learn how to integrate new ways of doing things into their clinical practices via a peer-to-peer teaching model.

� Expanding to include specialist physicians.

� Supported by the GP Services Committee, Specialist Services Committee & Shared Care Committee (partnerships between the Ministry of Health Services and the BC Medical Association, including the Society of General Practitioners) and Regional Health Authorities.

BC Practice Support Program (PSP)

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� Overall goal: To give participants tools they can use in their practice to improve care and to support them as they try to use these tools.

� Structure:

› Pre-work

› 3 Learning sessions:

� Half day sessions with GP/MOA teams, Specialists and Community Allied Health Professionals (possibly NGOs in some communities)

› 2 Action Periods:

� Change concepts are implemented during the periods between learning sessions.

� Not CME, but eligible for CME Credits for both GPs and Specialists.

Structured Learning Collaborative

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Role: To teach content/ change concepts to their peers at a local level.

Qualifications: Those who

� Enjoy teaching in an interactive & informal context

� Are passionate about the clinical topic area.

Supports for role:

� Champions are reimbursed for their time spent doing PSP work.

� Experienced PSP coordinators

GP Champions

� Champion

[def’n]: A peer

who has special

experience or

skills and mentors others

� Principle: A teacher as similar

to the student as

possible

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� Support content development

� Support physicians during action

periods to ensure the role is manageable and not disruptive to clinical responsibilities.

� Facilitate communication among local

providers/practice peers and care delivery across the continuum

� Ongoing support for practices with practice change and action periods

� Monthly phone calls

� List-serve to share learning as it happens

PSP Coordinators

Team Functions:

Knowledgeable, local support available in all three domains: Clinical, Practice Management, & IMIT

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Clinical

2 3 4

1 2 3 4

IMIT

1 2 3 4

Practice Management

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

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Practice Support Program:End-of-Life Module

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� Improve the care of patients and families living with,

suffering and dying from life-limiting and chronic

illnesses by:

› Early Identification (Registry Building)

› Enhance and Improve physician confidence related to End of

Life care (e.g. care planning, forms, communication, resources)

› Improve Collaboration (clarity of roles, appropriate resource

referrals, network of community resources, etc)

› Improve the experience of the patient, family, physician, MOA and healthcare providers in End of Life care.

Module Aim

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› To improve the care of patients and families living with,

suffering and dying from life-limiting and chronic illnesses by:

› Improving collaboration:

� Identifying and referring appropriate patients to specialty

palliative care and others for consultation and services.

� Understanding provider needs, clarifying roles, tools and

resources for practice support and collaboration.

� Improving collaborative care planning, coordination and

communication with patients/caregivers and physicians and

other local health care and community providers.

“Integration in Action”

Module Aim (continued)

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Palliative Approach: Care through all the transitions

Patient Journey

McGregor and Porterfield 2011

Time of

Diagnosis

Decompensation

experiencing life limiting

illness

Decline and last days

Dependency and

symptoms increase

Death and bereavement

Transition 1 Transition 5Transition 4Transition 3Transition 2

Early

Chronic Disease

Management

Survivorship

Seniors at risk

Disease advancement

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Best practice: Collaborative and Interdisciplinary

Palliative Care Australia

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� Include patients with advanced disease:

› Cancer

› AIDS

› COPD and other chronic respiratory conditions

› Chronic heart disease

› Renal failure

› Neurological conditions, including dementia

› Frailty or multiple co-morbidities

� Consider patients in residential care as a target population

Target Population

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� Patient, family and informal network

� Family physician

� Specialist Physician (Oncology, IM)

� Community pharmacist

� Home Health / Community Care

› Nurses/rehab/home support

� Nurse practitioners, community RT

� Disease specific consultants / services

� Hospice palliative care consult teams

Who is the patient’s care team?

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� Participation of Home and Community Care

at Learning Sessions and Train the Trainer

Sessions

� Creation of regionally-specific Integration

material where applicable

� Development of learning objectives and

action period activities for Home and Community Care

staff

� Evaluation includes the input from Home and

Community Care /Palliative Care staff

Collaboration with Home and Community Care/Palliative Care

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� 500 GPs with MOAs (recent approval to

increase to 900)

� 100 H&CC/palliative care staff ~

1H&CC/PC: 5 GPs

� 30 - 50 specialist physicians

� 40-50 PSP Coordinators

Who is involved in the PSP EOL module?

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Through the

past year…

Evaluation: Early Learnings

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� Two Surveys

› Baseline to April 30, 2012 (administered at beginning of LS1)

› End-of-Module to August 31, 2012 (administered at end of LS3)

� Three groups of survey respondents

› GPs� Baseline: N=308, response rate = 72.5%

� End-of-Module: N=155, response rate = 48.7%

› MOAs� Baseline: N=180, response rate = 62.9%

� End-of-Module: N=67, response rate = 36.4%

› Home and Community Care and Palliative Care (HCC/PC) nurses� Baseline: N=27, response rate = 23.4%

� End-of-Module: N=7, response rate = 10.4%

Evaluation: Early Learnings

Satisfaction with the EOL Module

97.4

89.0

71.2

94.197.0 98.5

9.113.6

89.6

69.2

90.8

85.7

100.0

28.6 28.6

100.0

91.0

29.0

34.8

0

20

40

60

80

100

The material was

clear and

informative.

The facilitators

were well

informed and

knowledgeable.

Pacing of

sessions was

too slow.

Respondent

already knew

much of the

material.

Networking and

sharing of

information was

helpful.

Required action

period activities

could be

completed in

time allocated.

Respondent

learned

something new

that he/she

incorporated into

his/her practice.

%R

esp

on

de

nts

wh

o A

gre

ed

or

Str

on

gly

Ag

ree

d

GPs (N=155) MOAs (N=67) HCC/PC Nurses (N=7)

* Responses for questions with N<7 are not shown

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Practices Related to End of Life Care N

Mean Rating1 or

% GPs “Yes” t- or z-

value 2p-

value 3

Pre Post

Do you currently have a registry for

patients requiring end of life care?

213

1069.4% 72.6% z = 11.57 <.001

Do you currently have an action plan for

patients who require end-of-life care?209

10129.2% 69.3% z = 6.70 <.001

Do you currently participate in

collaborative care with HCC and/or PC

providers?

212

1072.25 2.30 t = 0.46 .642

Do you generally follow the most recent

clinical guidelines for palliative care?202

10064.9% 89.0% z = 4.44 <.001

Do you currently conduct home visits for

patients requiring end-of-life care?214

1042.73 2.60 t = 0.98 .327

Notes:1 The rating responses ranged from “always” (1) to “never” (5); thus smaller numbers indicate a higher frequency of

occurrence.2 The t-value is reported for the dependent-samples t-test on the means, with the degrees of freedom of (N-1).

The z-value is reported for a z-test on two proportions.3 Statistically significant results, at the .05 level, are shown in bold.

GP’s Practices Changes Related to EoL Care Provision

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GP’s Changes in Confidence: Abilities Related to Providing EOL Care

EOL-Related Targeted AbilitiesMean1

t-

value

p-

valuePre Post

Identify patients who may benefit from palliative approach to care 1.79 1.47 4.32 <.001

Initiate a conversation about EOL care with a patient & his/her family 1.89 1.50 4.98 <.001

Guide the patient with regards to his/her goals of care at the end of

life2.05 1.65 4.94 <.001

Develop an action plan for your patients requiring end-of-life care 2.42 1.78 7.37 <.001

Communicate patient’s needs/wishes to other HCPs, as appropriate 1.94 1.60 4.14 <.001

Participate in collaborative care with HCC nurses 1.84 1.66 2.14 .033

Access/refer patients toEOL specialists in the community, as needed 1.94 1.59 4.05 <.001

Develop and maintain “shared care” relationships with non-PC

medical specialists2.06 1.75 3.78 <.001

Support a patient during the terminal phase of his/her illness and

address his/her concerns1.87 1.56 3.84 <.001

Support the patient’s family during grief and bereavement and

address their concerns1.86 1.61 3.09 .002

Note:1 The rating responses ranged from “very confident” (1) to “not at all confident” (4); thus smaller numbers indicate a higher level of

confidence.

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� All groups of participants were satisfied with the EOL learning module

� The EOL module has had a positive impact on GP practices and patients

� GPs’ and MOAs’ confidence in addressing the concerns of EOL patients has increased, compared with baseline measures

� Preliminary results show that the relationships between general practices and the home and community care providers are improving, but there are opportunities to strengthen these further

Conclusion

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Thank You